inpatient guideline final 4-30-07

8/14/2019 Inpatient Guideline Final 4-30-07

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Copyright 2007 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document which omits Joslins name or copyright notice is prohibited.

This document may be reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written

permission of Joslin Diabetes Center, Publications Department, 617-226-5815.

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JOSLIN DIABETES CENTER and JOSLIN CLINIC

GUIDELINE for INPATIENT MANAGEMENT OF SURGICAL and ICU PATIENTS

(Pre, Peri and Postoperative Care) 4/30/07

The Joslin Clinical Guideline for Inpatient Management of Surgical Patients with Diabetes is designed to assist primary care physicians and

specialists to individualize the care and set goals for adult, non-pregnant patients with diabetes who are undergoing surgery. This Guideline

focuses on the unique needs of the patient with diabetes. It is not intended to replace sound medical judgment or clinical decision-making and

may need to be adapted for certain patient care situations where more or less stringent interventions are necessary.

The objectives of the Joslin Clinical Diabetes Guidelines are to support clinical practice and to influence clinical behaviors in order to

improve clinical outcomes and assure that patient expectations are reasonable and informed. Guidelines are developed and approved throughthe Clinical Oversight Committee that reports to the Joslin Clinic Medical Director of Joslin Diabetes Center. The Clinical Guidelines are

established after careful review of current evidence, medical literature and sound clinical practice. This Guideline will be reviewed

periodically and modified as clinical practice evolves and medical evidence suggests.

SURGERY ALGORITHM: FOR PATIENTS WITH EXISTING DIABETES

The Joslin Clinical Guideline for Inpatient Management of Surgical Patients with Diabetes and ICU Patients uses one formula for splitting theinsulin; other reasonable formulae exist and are also acceptable.

Aim for Early AM Booking

Day and Evening Prior to Surgery:

Usual diet and insulin dose (NPH, glargine, detemir, regular, aspart, glulisine, lispro, inhaled insulin, insulin via pump, 70/30,75/25, or 50/50 insulin) or oral antihyperglycemic medications

Check blood glucose (BG) at bedtime; if BG > 180 mg/dl, instruct patient to take insulin according to subcutaneous algorithmor per individualized instructions; if hypoglycemic at bedtime or overnight, instruct patient to treat with glucose gel

Morning of Surgery

If fasting after midnight, give usual dose intermediate (NPH) or full dose long-acting (glargine or detemir) insulin; no changein basal rate for insulin pump patients; no rapid or short-acting insulin; no oral antihyperglycemic medication; no exenatide or

pramlintide

If the patient is coming in from home on pre-mixed insulin (70/30, 75/25, 50/50) and is NPO, less than of the usual morningdose is recommended to avoid hypoglycemia. The optimal regimen would be to give the usual morning dose as NPH insulin.

If not fasting, give usual dose of insulin Check BG every 2 hours before and during surgery; insulin pump patients can maintain basal rate during surgery or be changed

to IV insulin infusion or subcutaneous injections to maintain blood glucose target.

Maintenance of Hydration

During surgery the patient should receive maintenance IV fluids without dextrose (e.g. LR rather than D5LR). If an insulin infusion is required, D5W at 40 ml/hr or D10W at 20 ml/hr should be started to provide adequate substrate. This is

not required if adequately managed with subcutaneous insulin.

Patients receiving insulin infusion should receive at least 50 g glucose/24 hours.Major Surgery Non-Major Surgery

BG < 80 mg/dl BG 80-100 mg/dl BG 101-150 mg/dl BG > 150 mg/dlE.g., chest or abdominal cavity, LE bypass,transplant, spinal or brain surgery requiringgeneral anesthesia, total hip or kneereplacement, surgery anticipated to be > 4 hours

Give at least 100 mlD10W IV or 25 50 ml

(1/2 1 amp) of D50

Begin D5W at 40ml/hour or D10 W at

20 ml/hourCheck BG in 1 hour

Continue to monitorBG every 2 hours

Start IV Insulin(See Insulin Infusion Algorithm pg. 2) Check BG in 15-30 min.

Begin IV insulin(See Insulin Infusion

Algorithm pg. 2)

or

subcutaneous insulinalgorithm

Postoperative Management

Check BG when patient returns to postanesthesia unit; base frequency on BG during surgery Administer insulin according to subcutaneous algorithm or insulin infusion algorithm


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Alternative Initial Dose

Blood glucose (mg/dl) Regular Insulin (bolus) Regular Insulin (infusion per hour)

151-200 No Bolus 2 units IV

201-250 3 units IV 2 units IV



>350 10 units IV 4 units IV

Check BG Hourly

RECOMMENDED

INSULIN INFUSION ALGORITHM FOR INTRAOPERATIVE and MEDICAL ICU

(Target BG 101 150 mg/dl)

Insulin dose adjustments using this algorithm do not replace sound medical judgment.

*Whichever is greater change Previous Blood Glucose (mg/dl)

400

100 mg/dl and then re-initiate

drip at 50% previous rate

60-80 Hold drip and check BG every 30 minutes until >100 mg/dL and then re-initiate drip at 50% previous rate

81-100 rate by

1unit/hr

No

change rate by 25% or

0.5 units/hr* rate by 50% or 2 units/hr*

rate by 75% or

2 units/hr*

101-150 No Change rate by 50% or 2 units/hr*

151-200 rate by 1 unit/hr rate by 0.5

units/hr

rate by25% or

1 unit/hr*No Change rate by 25% or 2 units/hr*

201-250 rate by 25% or 2 units/hr* rate by 25% or 1 unit/hr* rate by1 unit/hr

No

Change

251-300 rate by 33% or 2.5 units/hr*

rate by

25% or1.5

units/hr*

rate by25% or

1 unit/hr*

rate by 1unit/hr

rate by1.5

units/hr

rate by25% or

2 units/hr*

NoChange

301-400 rate by 40% or 3 units/hr*

Cu

rrentBloodGlucose(mg/dl)

>400 rate by 50% or 4 units/hr*

This algorithm assumes hourly BG checks during insulin dose titration.

If BG in desirable range (101-150 mg/dl) for 4 hours can decrease frequency of BG checks to every 2 hours while BG stays in target.

If experiencing unexplained hypoglycemia or hyperglycemia, investigate and correct causative factors.

If there is any significant change in glycemic source (i.e., parenteral, enteral or oral intake), expect to make insulin adjustment.

Common reasons to discontinue insulin infusion:

Patient tolerating at least 50% of normal oral intake or enteral feedings Clinically appropriate to transfer patient to a unit that does not do insulin infusions Patient on stable regimen of TPN with most of insulin already in TPN solution


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Two hours before discontinuing insulin infusion, initiate alternative glycemic management:

For type 1 DM and type 2 DM previously controlled on insulin: If NPO, initiate basal subcutaneous insulin (glargine,detemir or NPH) at 80% of the insulin administered over the previous 24 hours by insulin infusion. If the patient is taking

more than 50% of usual oral or enteral intake, give 50% of insulin dose as basal based on previous 24 hours of insulin infused

or0.25 units/kg andinitiate pre-meal bolus and correction dose to maintain BG in target. Another alternative is to resume

pre-hospital insulin regimen. Insulin pump patients can resume pump use based on hospital policy.

For type 2 DM previously on oral antihyperglycemic agents: If patient had good diabetes control previousto hospitalization, a return to oral agent therapy may be considered based on postoperative clinical status; if pre-

hospital control was poor, plan for discharge on subcutaneous insulin.

OPTIONAL

INSULIN INFUSION ALGORITHM FOR LOWER GLUCOSE TARGETS

(Target BG 80 110 mg/dl)

Insulin dose adjustments using this algorithm do not replace sound medical judgment.

Some evidence suggests a higher incidence of hypoglycemia using these lower glucose targets. There is disagreement among

experts about the degree of glycemic control needed to decrease morbidity and mortality while avoiding severe hypoglycemia.

The following meets the AACE recommendations.

*Whichever is greater change Previous Blood Glucose (mg/dl)

400

100 mg/dl and then re-initiate

drip at 50% previous rate

60-80 Hold drip and check BG every 30 minutes until >100 mg/dl and then re-initiate drip at 50% previous rate

81-110 No change rate by 0.5

units/hr

rate by 50% or 2units/hr*

rate by 75% or2 units/hr*

111-150 rate

by 1

unit/hr rate by 0.5 units/hr No change rate by 50% or 2 units/hr*

151-200 rate by 1 unit/hr rateby 0.5

units/hr

rate by 1 unit/hr No

Change rate by 25% or 2 units/hr*

201-250 rate by 25% or 2 units/hr* rate by 25% or 1 unit/hr* rate by1 unit/hr

NoChange

251-300 rate by 33% or 2.5 units/hr* rate by

25% or 1.5

units/hr*

rate by

25% or

1 unit/hr*

rate by1 unit/hr

rate by1.5 units/hr

rate by

25% or

2 units/hr*

No

Change

301-400 rate by 40% or 3 units/hr*

CurrentBloodGlucose(mg/dl)

>400 rate by 50% or 4 units/hr*

This algorithm assumes hourly BG checks during insulin dose titration.

If BG in desirable range (81-110 mg/dl) for 2-3 hours can decrease frequency of BG checks to every 2 hours while BG stays in target.

If experiencing unexplained hypoglycemia or hyperglycemia, investigate and correct causative factors.If there is any significant change in glycemic source (i.e., parenteral, enteral or oral intake), expect to make insulin adjustment.

Common reasons to discontinue insulin infusion:

Patient tolerating at least 50% of normal oral intake or enteral feedings Clinically appropriate to transfer patient to a unit that does not do insulin infusions Patient on stable regimen of TPN with most of insulin already in TPN solution




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Two hours before discontinuing insulin infusion, initiate alternative glycemic management:

For type 1 DM and type 2 DM previously controlled on insulin: If NPO, initiate basal subcutaneous insulin (glargine,detemir or NPH) at 80% of the insulin administered over the previous 24 hours by insulin infusion. If the patient is taking

more than 50% of usual oral or enteral intake, give 50% of insulin dose as basal based on previous 24 hours of insulin infused

or0.25 units/kg andinitiate pre-meal bolus and correction dose to maintain BG in target. Another alternative is to resume

pre-hospital insulin regimen. Insulin pump patients can resume pump use based on hospital policy.

For type 2 DM previously on oral antihyperglycemic agents: If patient had good diabetes control previous tohospitalization, a return to oral agent therapy may be considered based on postoperative clinical status; if pre-hospital control

was poor, plan for discharge on subcutaneous insulin.

Glossary

AACE American Association of Clinical Endocrinologists IV Intravenous NS Normal saline

BG Blood glucose LE Lower extremity Subcut - subcutaneously

DM Diabetes mellitus LR Lactated Ringers TPN Total parenteral nutrition

ICU Intensive care unit NPO Nothing by mouth

Approved by Clinical Oversight Committee on 4/30/07.

Guideline Task Force: Co-chairs James Rosenzweig, MD and Elaine Sullivan, MS, RN, CDE; Martin J.Abrahamson, MD, Mark Aronson, MD,George Blackburn, MD, PhD, Vasti Broadstone, MD, Amy Campbell, MS, RD, CDE, Roberta Capelson, MS, ANP, Justine Carr, MD, DavidFeinbloom, MD, Patricia Folcarelli, MS, RN, Michael Howell, MD, Lyle Mitzner, MD, Steven Quevedo, MD, Patricia Samour, MMSc, RD,

Marjorie Serrano, RN, Kenneth Snow, MD, Balachundhar Subramaniam, MD

References:ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement oninpatient diabetes and glycemic control. Endocr Pract12:4-13, 2006.

Bolk J, van der Ploeg T, Cornel JH, Arnold AE, Sepers J, Umans VA. Impaired glucose metabolism predicts mortality after a myocardial infarction.

Int J Cardiol 79:207-214, 2001.

Hwaite SS, Godara H, Song HJ, Rock P. No patient left behind: Evaluation and design of intravenous insulin infusion algorithms. Endocr Pract12:72-78, 2006.

Browning LA, Dumo P. Sliding-scale insulin: An antiquated approach to glycemic control in hospitalized patients.Am J Health Syst Pharm 61:1611-1614, 2004.

Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycemia and increased risk of death after myocardial infarction in patients with andwithout diabetes: a systematic overview.Lancet 355:773-778, 2000.

Carr JM, Sellke FW, Fey M, Doyle MJ, Krempin JA, de la Torre R, Liddicoat JR. Implementing tight glucose control after coronary artery bypass

surgery.Ann Thorac Surg 80:902-909, 2005.

Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsh IB. Management of diabetes and hyperglycemia in hospitals.

Diabetes Care 27:553-591, 2004.

Egi M, et al. Intensive insulin therapy in postoperative intensive care unit patients.Am J Respir Crit Care Med173: 407-413, 2006.

Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusion on outcomes of cardiac surgical procedures:The Portland Diabetic Project.Endocr Pract10 (suppl 2): 21-33, 2004.

Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, Williams BA, Schrader LM, Rizza RA, McMahon MM. Intraoperative hyperglycemiaand perioperative outcomes in cardiac surgery patients.Mayo Clin Proc 80:862-866, 2005.

Goldberg PA, Siegel MD, Sherwin RS, Halickman JI, Lee M, Bailey VA, Lee SL, Dziura JD, Inzucchi SE. Implementation of a safe and effectiveinsulin infusion protocol in a medical intensive care unit.Diabetes Care 27:461-467, 2004

Haas L. Improving inpatient diabetes care: Nursing issues.Endocr Pract12:56-60, 2006.

Hirsch I. Inpatient diabetes: Review of data from the cardiac care unit. Endocr Pract12:27-34, 2006.

Inzucchi SE. Management of hyperglycemia in the hospital setting.N Engl J Med355:1903-11, 2006.

Malhotra A. Intensive insulin in intensive care.N Engl J Med354:516-518, 2006.

Najarian J, Swavely D, Wilson E, Merkle L, Wasser T, Hesener Quinn A, Urffer S, Young M. Improving outcomes for diabetic patients undergoingvascular surgery.Diabetes Spectr18:23-60, 2005.

Pittas AG, Siegel RD, Lau J. Insulin therapy and in-hospital mortality in critically ill patients: Systematic review and meta-analysis of randomizedcontrolled trials.J Parenter Enteral Nutr30:164-172, 2006.

Schnell O, Schafer O, Kleybrink S, Doering W, Standl E, Otter W. Intensification of therapeutic approaches reduces mortality in diabetic patients

with acute myocardial infarction.Diabetes Care 27:455-460, 2004.

Swift CS, Boucher JL. Nutrition care for hospitalized individuals with diabetes. Diabetes Spectr18:34-38, 2005.

Swift CS, Boucher JL. Nutrition therapy for the hospitalized patient with diabetes.Endocr Pract12:61-67, 2006.


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Van den Berghe G. Insulin vs. strict blood glucose control to achieve a survival benefit after AMI?Eur Heart J26:639-641, 2005.

Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R. Intensive insulintherapy in the medical ICU. N Engl J Med354: 449-461, 2006.

Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med345:1359-1367, 2001.

Vanhorebeek I, Langouche L, Van den Berghe G. Intensive insulin therapy in the intensive care unit: Update on clinical impact and mechanisms ofaction.Endocr Pract12:14-21, 2006.

JOSLIN CLINICAL OVERSIGHT COMMITTEE

James Rosenzweig, MD - Chairperson

Richard Beaser, MDElizabeth Blair, MS, CS-ANP, CDEPatty Bonsignore, MS, RN, CDEAmy Campbell, MS, RD, CDECathy Carver, ANP, CDE

Jerry Cavallerano, OD, PhD

Om Ganda, MD

David Feinbloom, MDJohn Hare, MDLori Laffel, MD, MPHMelinda Maryniuk, MEd, RD, CDEMedha Munshi, M

William Petit, MD

Kristi Silver, MD

Susan Sjostrom, JDKenneth Snow, MDRobert Stanton, MDWilliam Sullivan, MDHoward Wolpert, MD

Martin Abrahamson, MD (ex officio)




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inpatient guideline final 4-30-07

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